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•JMI■ JVM4(�JIF�1 Vwwim 1 1 L—iwvir%wtms11L1�1IML IILML111 VLr'MI\11Y1L1tl 1 r <br /> I MAS T ERFILE RECORD IINFORMH I IOM FORM t <br /> New EH Program at Existing Facili ❑New EH Pro ram and New Facility <br /> Facilit ID �,AO� �� �G Program Record ID ?1j2 3(,(o <br /> Facility Address LM Ocn LA 45�(0(0 <br /> (Please check the appropriate description and specify size, number of units and pertinent information.) <br /> FOOD PROGRAM(1600) <br /> ❑ Restaurant: Seating CapacitySquare Footage Food Handlers Course required: YEsOU No ❑ <br /> Commissary ❑ Dry storage only 21with Food Preparation ❑Vending Machines Number of Units <br /> ❑ Retail Market--Square footage ❑ wlMeat Market only ❑ Multiple Departments❑ Prepackaged Goods Only <br /> ❑ Mobile Food Vehicle–Make Vehicle Type Color <br /> Registration# License# Sticker# <br /> u Mobile Food Prep Unit–Make Vehicle T ype Color <br /> Registration# License# Sticker# <br /> ❑ Temporary Food Facility–Dates of operation from to ❑ Ice Plant❑ Produce Stand <br /> ❑ Special Event---Dates of operation from to ❑ CFO ❑ A❑ B <br /> DAIRY PROGRAM (2040) <br /> ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit <br /> CUPA <br /> ❑ Hazardous Materials Business Plan (1900) Number of chemicals: <br /> ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility <br /> ❑ Hazardous Waste Generator(2200)------>-Tons Generated Per Year <br /> ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233,2234,2235, 2237) ❑ PBR(2231) ❑ PBR HHW(2236) <br /> ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs <br /> ❑Underground Storage Tank Program(UST)(2300) Use UST A and B forms <br /> ❑Other CUPA Program <br /> HOUSING PROGRAM(2400) <br /> ❑ Hotel/Motel—Number of Units ❑ Jail or Exempt Institution—Number of Units <br /> Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site © NPUSEP Cleanup Site ❑ UIC Site <br /> ❑ Abandoned HW Site 11 non-NPUSEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br /> RECREATIONAL HEALTH PROGRAM(3600) <br /> Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br /> VECTOR CONTROL PROGRAM(4000) <br /> ❑ Poultry Farm---Maximum number of birds ❑ Kennel <br /> TATTOO, BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) <br /> ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) <br /> ❑ Body Art Facility-Sterilization (4121) [] Body AR Temp Event Co-ord(4130) ❑ Body Art Temp Event Mobile Facility(4131) <br /> LIQUID WASTE PROGRAM!(4200) <br /> ❑ Pumper Vehicle Registration# License# Capacity Vehicle# <br /> ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets—Number of Units <br /> SOLIDWASTE PROGRAM(4400) <br /> ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludae/Ash Site <br /> ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br /> ❑ Refuse Vehicles(#or Units) ❑ Dumpsters>20 cu yd (#of units) ❑ Farm/Ranch Cleanup Site <br /> MEDICAL WASTE PROGRAM(4500) <br /> ❑ Primary Care ❑ Acute Care 0 Skilled Nursing ❑ Large Generator ❑ Small Generator ❑ Limited Hauler <br /> ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility ❑ 2-10 ❑ 11 -60 ❑ >60 generators <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46-02-003 Blue Anplicadon Form <br /> EMERGENCY NOTIFICATION FOR THIS FACILrrY AND/OR PROGRAM <br /> CONTACT PERSON 1 C. Day Ph [ L- Iv Night Ph -)LO <br /> PROGRAM ELEMENT FEE ❑ Surcharge FEE ❑ Other FEE <br /> INSPECTOR# PERMIT VALID to ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> 0 Cash REVIEWED BY ACCOUNTING OFFICE Date <br />